Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment.

BACKGROUND: Quality improvement (QI) initiatives are increasingly used to improve the quality of care and reduce prescribing errors. The Royal College of General Practitioners (RCGP) and Clinical Practice Research Datalink (CPRD) QI initiative uses routinely collected electronic primary care data to provide bespoke practice-level reports on prescribing safety. The aim of this study was to explore how the QI reports were used, barriers and facilitators to use, long-term culture change and perceived impact on patient care and practices systems as a result of receiving the reports. METHODS: A qualitative study using purposive sampling of practices contributing to the CPRD, semi-structured interviews and inductive thematic analysis. We interviewed general practitioners, pharmacists, practice managers and research nurses. RESULTS: We conducted 18 interviews, and organised themes summarising the use of QI reports in practice: receiving the report, facilitators and barriers to acting upon the reports, acting upon the report, and how the reports contribute to a quality culture. Effective dissemination of reports, and a positive attitude to audit and the perceived relevance of the clinical topic facilitated use. Lack of time and failure to see or act upon the reports meant they were not used. Factors influencing use of the reports included the structure of the report, ease of identifying cases, and perceptions about coding accuracy. GPs and pharmacists used the reports to conduct case reviews and directly contact patients to discuss unsafe prescribing and patient medication preferences. Finally, the reports contributed to the development of a quality culture within practices through promoting audit activity and acting as a reminder of good prescribing behaviours, promoting future patient safety initiatives, contributing to continuing professional development and improving local networks. CONCLUSIONS: This study found the reports facilitated individual case review leading to an enhanced sense of quality culture in practices where they were utilised. Our findings demonstrate that the reports were generally considered useful and have been used to support patient safety and clinical practice in specific cases.

A BEME systematic review of UK undergraduate medical education in the general practice setting: BEME Guide No. 32.

BACKGROUND: General practice is increasingly used as a learning environment in undergraduate medical education in the UK. AIM: The aim of this project was to identify, summarise and synthesise research about undergraduate medical education in general practice in the UK. METHODS: We systematically identified studies of undergraduate medical education within a general practice setting in the UK from 1990 onwards. All papers were summarised in a descriptive report and categorised into two in-depth syntheses: a quantitative and a qualitative in-depth review. RESULTS: 169 papers were identified, representing research from 26 UK medical schools. The in-depth review of quantitative papers (n = 7) showed that medical students learned clinical skills as well or better in general practice settings. Students receive more teaching, and clerk and examine more patients in the general practice setting than in hospital. Patient satisfaction and enablement are similar whether a student is present or not in a consultation, however, patients experience lower relational empathy. Two main thematic groups emerged from the qualitative in-depth review (n = 10): the interpersonal interactions within the teaching consultation and the socio-cultural spaces of learning which shape these interactions. The GP has a role as a broker of the interactions between patients and students. General practice is a socio-cultural and developmental learning space for students, who need to negotiate the competing cultures between hospital and general practice. Lastly, patients are transient members of the learning community, and their role requires careful facilitation. CONCLUSIONS: General practice is as good, if not better, than hospital delivery of teaching of clinical skills. Our meta-ethnography has produced rich understandings of the complex relationships shaping possibilities for student and patient active participation in learning.

Quality of care for chronic diseases in a British cohort of long-term cancer survivors.

PURPOSE: Previous research has shown that long-term cancer survivors with other chronic diseases may receive poorer care for those diseases compared with the general population. We sought to establish the quality of care for chronic diseases among cancer survivors in the United Kingdom. METHODS: From the UK General Practice Research Database, we identified 21,366 adult patients who had survived 5 or more years after a diagnosis of breast, colorectal, or prostate cancer with a diagnosis of hypertension, coronary artery disease, diabetes, or cerebrovascular disease. For each patient, an age-sex matched noncancer control patient was selected from the same general practice and with the same chronic disease. We compared the chronic disease care in cancer survivors and their matched controls. RESULTS: The proportion of patients meeting quality standards for chronic disease care was high in both cancer survivors and control patients. Although cancer survivors were slightly less likely to receive blood pressure monitoring and cholesterol tests, this difference was no longer apparent if patients who died during the study period were excluded. For instance, 93% of breast cancer survivors received blood pressure monitoring compared with 94% of matched control patients. Similarly, control of disease was comparable among all patients, with the exception of diabetic prostate cancer survivors, who had fewer cholesterol readings under the control limit (17% reduction, 95% CI, 7%-26%) and diabetic colorectal survivors, who had fewer calendar quarters of glycated hemoglobin control (12% reduction, 95% CI, 2%-23%). CONCLUSIONS: Care of comorbidities is not neglected in the United Kingdom because people have had a previous diagnosis of cancer. One explanation is that in the United Kingdom, such care is provided through a robust primary care system.

Adaptation and validation of the Charlson Index for Read/OXMIS coded databases.

BACKGROUND: The Charlson comorbidity index is widely used in ICD-9 administrative data, however, there is no translation for Read/OXMIS coded data despite increasing use of the General Practice Research Database (GPRD). Our main objective was to translate the Charlson index for use with Read/OXMIS coded data such as the GPRD and test its association with mortality. We also aimed to provide a version of the comorbidity index for other researchers using similar datasets. METHODS: Two clinicians translated the Charlson index into Read/OXMIS codes. We tested the association between comorbidity score and increased mortality in 146 441 patients from the GPRD using proportional hazards models. RESULTS: This Read/OXMIS translation of the Charlson index contains 3156 codes. Our validation showed a strong positive association between Charlson score and age. Cox proportional models show a positive increasing association with mortality and Charlson score. The discrimination of the logistic regression model for mortality was good (AUC = 0.853). CONCLUSION: We have translated a commonly used comorbidity index into Read/OXMIS for use in UK primary care databases. The translated index showed a good discrimination in our study population. This is the first study to develop a co-morbidity index for use with the Read/OXMIS coding system and the GPRD. A copy of the co-morbidity index is provided for other researchers using similar databases.

Long-term survivors of adult cancers and uptake of primary health services: a systematic review.

AIM: The aim of this paper is to systematically review the literature on the use of primary and community care services by long-term survivors of adult cancers. METHODS: We conducted a systematic search of eight databases and considered papers looking at primary care aspects of surviving cancer at least 3 years past diagnosis. RESULTS: Ten eligible papers in four categories: consultation rates in primary care, cancer screening, use of preventative services and chronic disease management. There was no conclusive evidence that cancer survivors have increased rates of consultation in primary care. The studies reported that cancer screening is well managed in survivors. Preventative and chronic care is worse in long-term colorectal cancer survivors compared with long-term breast cancer survivors and controls. CONCLUSION: We found little research, especially outside the United States, relating to the care of long-term cancer survivors in primary care. Future work should examine screening for treatment-specific sequelae and the quality of care for co-morbid disease.

Quality of diabetes care in breast, colorectal, and prostate cancer.

PURPOSE: Overlooking other medical conditions during cancer treatment and follow-up could result in excess morbidity and mortality, thereby undermining gains associated with early detection and improved treatment of cancer. We compared the quality of care for diabetes patients subsequently diagnosed with breast, colorectal, or prostate cancer to matched, diabetic non-cancer controls. METHODS: Longitudinal cohort study using primary care records from the Clinical Practice Research Datalink, United Kingdom. Patients with pre-existing diabetes were followed for up to 5 years after cancer diagnosis, or after an assigned index date (non-cancer controls). Quality of diabetes care was estimated based on Quality and Outcomes Framework indicators. Mixed effects logistic regression analyses were used to compare the unadjusted and adjusted odds of meeting quality measures between cancer patients and controls, overall and stratified by type of cancer. RESULTS: 3382 cancer patients and 11,135 controls contributed 44,507 person-years of follow-up. In adjusted analyses, cancer patients were less likely to meet five of 14 quality measures, including: total cholesterol ≤ 5 mmol/L (odds ratio [OR] = 0.82; 95% confidence interval [CI], 0.75-0.90); glycosylated hemoglobin ≤ 59 mmol/mol (adjusted OR = 0.77; 95% CI, 0.70-0.85); and albumin creatinine ratio testing (adjusted OR = 0.83; 95% CI, 0.75-0.91). However, cancer patients were as likely as their matched controls to meet quality measures for other diabetes services, including retinal screening, foot examination, and dietary review. CONCLUSIONS: Although in the short-term, cancer patients were less likely to achieve target thresholds for cholesterol and HbA1c, they continued to receive high-quality diabetes primary care throughout 5 years post diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: These findings are important for cancer survivors with pre-existing diabetes because they indicate that high-quality diabetes care is maintained throughout the continuum of cancer diagnosis, treatment, and follow-up.

Outcomes of preexisting diabetes mellitus in breast, colorectal, and prostate cancer.

PURPOSE: Preexisting diabetes is associated with increased morbidity and mortality in cancer. We examined the impact of incident cancer on the long-term outcomes of diabetes. METHODS: Using the United Kingdom Clinical Practice Research Datalink, we identified three cohorts of diabetes patients subsequently diagnosed with breast, colorectal, or prostate cancer, each matched to diabetic noncancer controls. Patients were required to have survived at least 1 year after cancer diagnosis (cases) or a matched index date (controls), and were followed up to 10 years for incident microvascular and macrovascular complications and mortality. Multivariate competing risks regression analyses were used to compare outcomes between cancer patients and controls. RESULTS: Overall, there were 3382 cancer patients and 11,135 controls with 59,431 person-years of follow-up. In adjusted analyses, there were no statistically significant (p ≤ 0.05) differences in diabetes complication rates between cancer patients and their controls in any of the three cancer cohorts. Combined, cancer patients were less likely (adjusted hazard ratio [HR] 0.88; 95% CI = 0.79-0.98) to develop retinopathy. Cancer patients were more likely to die of any cause (including cancer), but prostate cancer patients were less likely to die of causes associated with diabetes (HR 0.61; 95% CI = 0.43-0.88). CONCLUSIONS AND IMPLICATIONS: There is no evidence that incident cancer had an adverse impact on the long-term outcomes of preexisting diabetes. IMPLICATIONS FOR CANCER SURVIVORS: These findings are important for cancer survivors with preexisting diabetes because they suggest that substantial improvements in the relative survival of several of the most common types of cancer are not undermined by excess diabetes morbidity and mortality.

Defining cancer survivorship: a more transparent approach is needed.

INTRODUCTION: There is a lack of a consistent, operational definition of what it means to be a cancer survivor despite widespread use of the term. The term carries positive connotations of 'beating' cancer, but some people living past cancer do not identify with this portrayal. METHODS: The term 'cancer survivor' was first developed and used in the USA for advocacy reasons and to promote research and care of this growing population. Some organizations define a cancer survivor from the time of cancer diagnosis. Researcher and policy makers may use different definitions based on their research or funding priorities. RESULTS: The use of the term 'cancer survivor', its acceptability and its interpretation amongst people living past a cancer diagnosis and primary treatment is relatively understudied. There may be numerous interpretations of cancer survivorship amongst people living past cancer, and some individuals may not relate to the term. DISCUSSION AND IMPLICATIONS FOR CANCER SURVIVORS: Instead of working towards a universal definition of cancer survivorship, we suggest that researchers and policy makers use operational descriptions when discussing the diverse population of people living past a cancer diagnosis.

Primary care consultation behaviours of long-term, adult survivors of cancer in the UK.

The population of cancer survivors is growing, and GPs have an increasing role in their care. The General Practice Research Database was used to compare consultation rates between cancer survivors and controls. Breast and colorectal cancer survivors had one more consultation per year compared with controls up to 5 years after diagnosis; rates then converged at 10 years post-diagnosis. Prostate cancer survivors consistently consulted up to three more times per year than controls. These increased consultation rates are leading to an impact on service capacity.

Primary health and supportive care needs of long-term cancer survivors: a questionnaire survey.

PURPOSE: There are 1.2 million long-term cancer survivors in the United Kingdom. Existing research on the health and supportive care needs of these survivors is sparse and inconclusive. This study investigated health status, psychological morbidity, and supportive care needs in long-term cancer survivors in the United Kingdom. METHODS: Five to 16 years after diagnosis, 1,275 eligible survivors of breast, colorectal, and prostate cancers were approached to participate in a questionnaire survey. The questionnaire explored health status (European Quality of Life-5 Dimensions), psychological morbidity (Hospital Anxiety and Depression Scale), and supportive care needs (Cancer Survivors' Unmet Needs Measure). Data were analyzed by type of cancer and time since diagnosis. Logistic regression was used to identify predictors of unmet supportive care needs. RESULTS: The response rate was 51.7% (659 survivors). Overall health status and levels of psychological morbidity were consistent with population norms. At least one unmet supportive care need was reported by 47.4% of survivors, but overall numbers of unmet needs were low (mean, 2.8; standard deviation, 4.8). The most frequently endorsed unmet need was for help to manage concerns about cancer recurrence. Trait anxiety (P < .001), nondischarged status (P < .01), dissatisfaction with discharge (P < .01), and receipt of hormonal therapy (P < .01) were predictive of unmet supportive care needs. CONCLUSION: The findings suggest a majority of long-term breast, colorectal, and prostate cancer survivors who have no signs of recurrence report good health and do not have psychological morbidity or large numbers of unmet supportive care needs. A minority of long-term survivors may benefit from ongoing support. The identification and support of those long-term survivors with ongoing needs is a key challenge for health care professionals.

Validity of diagnostic coding within the General Practice Research Database: a systematic review.

BACKGROUND: The UK-based General Practice Research Database (GPRD) is a valuable source of longitudinal primary care records and is increasingly used for epidemiological research. AIM: To conduct a systematic review of the literature on accuracy and completeness of diagnostic coding in the GPRD. DESIGN OF STUDY: Systematic review. METHOD: Six electronic databases were searched using search terms relating to the GPRD, in association with terms synonymous with validity, accuracy, concordance, and recording. A positive predictive value was calculated for each diagnosis that considered a comparison with a gold standard. Studies were also considered that compared the GPRD with other databases and national statistics. RESULTS: A total of 49 papers are included in this review. Forty papers conducted validation of a clinical diagnosis in the GPRD. When assessed against a gold standard (validation using GP questionnaire, primary care medical records, or hospital correspondence), most of the diagnoses were accurately recorded in the patient electronic record. Acute conditions were not as well recorded, with positive predictive values lower than 50%. Twelve papers compared prevalence or consultation rates in the GPRD against other primary care databases or national statistics. Generally, there was good agreement between disease prevalence and consultation rates between the GPRD and other datasets; however, rates of diabetes and musculoskeletal conditions were underestimated in the GPRD. CONCLUSION: Most of the diagnoses coded in the GPRD are well recorded. Researchers using the GPRD may want to consider how well the disease of interest is recorded before planning research, and consider how to optimise the identification of clinical events.

Consulting and prescribing behaviour for anxiety and depression in long-term survivors of cancer in the UK.

INTRODUCTION: Cancer survivors may experience long-term depression or anxiety, however, there is little previous research on the use of services in this area. We explored consultation and prescribing behaviour for depression and anxiety amongst cancer survivors in British primary health care. METHODS: This study uses data on 26,213 survivors of breast, colorectal and prostate cancer at least 5 years post-diagnosis, matched to four controls without cancer, from the UK General Practice Research Database. We compared consultations for depression and anxiety, and prescribing for anti-depressants and anxiolytics between cancer survivors and controls. RESULTS: Multivariate, matched regression models showed no difference in consulting for depression or anxiety between any cancer survivors and matched controls. However, breast cancer (odds ratio (OR) 1.16, 95% confidence interval (CI) 1.10-1.22) and prostate cancer survivors (OR 1.31, 95% CI 1.16-1.47) were more likely to receive a prescription for an antidepressant. Breast cancer survivors (IRR 2.49, 95% CI 1.82-3.42) and prostate cancer survivors (IRR 2.84, 95% CI 1.94-4.17) who died received significantly more antidepressants than controls who died. There were no differences in anxiolytic prescribing for colorectal and prostate cancer survivors compared to controls. However, breast cancer survivors nearing the end of life received a greater number of anxiolytic prescriptions compared to controls (IRR 1.84, 95% CI 1.36-2.49). CONCLUSIONS: In this cohort of cancer survivors, there were no differences in consultation behaviour for depression and anxiety compared to controls. However, breast and prostate cancer survivors access more antidepressants, and those nearing the end of life received the highest volume of prescriptions. Breast cancer survivors at the end of life also receive more anxiolytics.